Case Management by Computer

Missouri employs an electronic client level database to help carry out medical case management. The system records demographic data, verifies eligibility, captures service referral and utilization data, and more. The system, called FACTORS, creates and monitors care plans for both medical case management and psycho-social case management services for Ryan White clients.

FACTORS is based, in part, on client level databases created nearly a decade ago in Missouri (see below, Looking Back—and Ahead). FACTORS also replaced an old paper-based system, which was seen as less effective in helping case managers develop care plans and monitor success. The process of converting all case managers to electronic media took several years. It was facilitated by a statewide coordinated effort of all Ryan White grantees and the use of a single database administrator.

While States and communities across the Nation are using varied approaches to developing care plans, programs are united in their focus on implementing the Ryan White legislation’s increased emphasis on core medical services—linking clients into primary care. As a result, the work of case managers is more focused on engaging clients in health care services—and less on supportive services—under the medical case management model. The HIV Performance Measure on Medical Case Management developed by HRSA HIV/AIDS Bureau is designed to help programs implement this requirement in their quality management efforts.

The goal of case management is to assist clients in acquiring medical and support services to facilitate coordination of care and promote client self-management. - Missouri Case Management Manual, 2009

At the Front End: Preparing a Care Plan—Online

The focus of medical case management under the FACTORS system is engagement in medical care. However, Missouri’s system also seeks to provide clients with the services they need and to move them, over time, to less intensive levels of care as their self-management ability increases.

Missouri’s process for putting a care plan in place with a client is a two-part process, which is now computerized.

First, a case manager conducts a thorough acuity assessment to evaluate functioning in several life areas and inputs data on the following categories: Activities of Daily Living (ADL), Health, Personal/Economic Resources, and Psychosocial Issues. The acuity-based case management system is designed to ensure appropriate case management while targeting resources to those most in need.

The next step is development of a care plan, which is based upon the score for each of the 27 domains addressed. The structure of the care plan is in an outline tree format and is categorized into three areas.

The first care plan area is the goal statement, which articulates (for each client) the purpose of all services: to gain and maintain engagement in appropriate levels of HIV medical care.

Next is the narration of barriers to care. An item that scores greater than zero on the biopsychosocial acuity index (BAI) can be identified as a barrier. The scores can range from 0-7 depending on the level of need of the client. The notes in the BAI about the identified need can be pre-populated directly into the individual service plan (ISP) module in the database, preventing the need for duplicate entries of narrative.

The third care plan area is action items or an action plan where client and case manager actions are identified and assigned. The case manager works with the client to identify barriers the client is prepared to address and begins development of an action plan. If the client is unwilling to undertake an action plan to remove a barrier (e.g., substance abuse treatment, smoking cessation) the case manager notes that the client is not ready to address the barrier and the action plan is not written. The case manager does re-assess the barrier at intervals to see if client readiness has changed. The case manager has the ability to rate the progress of the client in reducing or removing barriers to gaining or maintaining HIV medical care. This is done with a rating feature that allows for individual entries, notes, and scores each time a barrier to care or action item is addressed.

Ongoing and Online: Monitoring Clients and Quality

The above two steps are just the front end of case management. The client level database is more comprehensive and also allows for monitoring and input of data to reflect ongoing case manager work with clients, including documentation of eligibility, subsequent assessments of acuity, referral for services to reduce barriers to care, and documentation of the use of other Ryan White-funded services that are available to pay for care and support services.

The client level database also allows case managers and system supervision to generate reports on the entire population of clients or just those of a single case manager. This ability has provided information to guide quality assurance and quality improvement activities. Some reports are generated monthly to assist case managers in the annual re-assessment and eligibility determination process. Other reports are used to generate information for reporting to consumers and funders or for grant applications. The statistics the electronic client database contains are as accurate and complete as the data the case manager enters. Increased accuracy and completeness is a product of the time and familiarity of the case managers entering the data as well as initial and on-going education and training.

Other uses of the client level database are being considered. One function being looked into by the Director of Case Management is finding a way to communicate the results of assessments or encounters directly to medical care providers. The goal is to create a circle of communication from provider to client to case manager and back to provider in order to assist clients in moving to higher levels of self-sufficiency.

Looking Back—and Ahead

FACTORS has quite a history and is, in fact, based upon many earlier efforts. The first began in 2002 under a Part A grantee’ initiative to create a client level database for their area. Building on their early success, other Ryan White grantees in Missouri gradually agreed to implement the same system over the following two years. The shared vision was to build a more efficient and coordinated system of case management and care under a single system.

The modules implemented first were those used to provide information for complete reporting to HRSA. They also allowed various system providers to access enrollment, eligibility, and referral information—thus, minimizing duplication of effort. Those modules included demographics, income, insurance, assessments, service referrals, and encounters (documentation of utilization). As the use of the system gained maturity additional features were implemented, including electronic service plans and more clinical modules to collect information for Ryan White client level data report under the RSR.

The electronic system reportedly works exceptionally well in Missouri, in part because of the committed effort to support and train users of the system. However, Missouri is at a cross-roads. The current FACTORS database used by Missouri was de-supported by its developer. The need for a replacement system that can be regularly updated and improved is immediate. Grantees have been working with the database administrator to write a program that will borrow from the strengths of the current system and improve upon those areas most in need of revision. One hoped-for area of improvement is to revise the service plan module to allow for closure of inactive or resolved entries, thus easing review of client service records.

Case Management Tools in Missouri

Missouri's Ryan White Part B Program has developed multiple tools to both improve case management services and implement the Ryan White HIV/AIDS Program’s increased focus on medical case management. Among these are the following:

The FACTORS computerized system for conducting medical case management (see main story).